Provider Demographics
NPI:1447470067
Name:COCKRUM, MICHAEL (LCSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:COCKRUM
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 TANGLEWOOD TRL # 2
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:TN
Mailing Address - Zip Code:37616-4532
Mailing Address - Country:US
Mailing Address - Phone:423-783-8900
Mailing Address - Fax:
Practice Address - Street 1:134 CECIL D QUILLEN DR
Practice Address - Street 2:
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:24244-9726
Practice Address - Country:US
Practice Address - Phone:276-431-1638
Practice Address - Fax:276-431-1639
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN09040057871041C0700X
TN00000032111041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical